Claims Auditor

About

Position: Claims Auditor
Location: Sandton
Industry: Managed Care
Reference: MCP-JHBClaims

A specialised opportunity for an experienced medical claims professional to join a high‑performance auditing environment. The role focuses on validating the legitimacy of medical aid claims, ensuring regulatory compliance, and mitigating financial and operational risk through thorough investigation and analysis.

Key Responsibilities

• Investigate the validity of claims using multiple data sources, interviews, site reviews, and detailed case analysis.
• Identify potential fraud, irregularities, or non‑compliant activity and escalate findings appropriately.
• Conduct interviews with claimants and witnesses to verify information and support accurate decision‑making.
• Review suspicious claims involving possible criminal activity, falsified documentation, or unnecessary procedures.
• Maintain accurate records, compile investigation reports, and present findings to relevant stakeholders.
• Collaborate with internal teams to strengthen processes, support service delivery, and uphold quality standards.
• Participate in continuous improvement, innovation, and knowledge development within the claims environment.

Requirements

• Matric and strong computer literacy.
• 3–5 years’ experience as a medical aid claims assessor or agent.
• Comprehensive understanding of medical aid claims processes.
• Knowledge of BHF, tariff structures, SAMA, ICD‑10 and CPT coding (advantageous).
• Experience with Oracle systems (advantageous).

Competencies

• Strong attention to detail and accuracy.
• Ability to detect patterns, anomalies, and potential fraud.
• Effective under pressure with strong time‑management skills.
• Collaborative, resilient, and able to manage multiple priorities.
• Skilled in risk‑based auditing and investigative analysis.